Healthcare Provider Details

I. General information

NPI: 1124460274
Provider Name (Legal Business Name): NORTHEAST COMMUNITY CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2013
Last Update Date: 06/12/2023
Certification Date: 06/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2975 ZOE AVE
HUNTINGTON PARK CA
90255
US

IV. Provider business mailing address

2550 W MAIN ST STE 301
ALHAMBRA CA
91801-7003
US

V. Phone/Fax

Practice location:
  • Phone: 323-771-8400
  • Fax: 323-582-8500
Mailing address:
  • Phone: 626-457-6900
  • Fax: 626-457-5022

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: DR. CHRISTOPHER LAU
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 626-457-6900